Coati

@aribindi @ThinkingCC @fersaurin I’m sure you’re plenty familiar with cardiogenic shock patients who decompensated despite best efforts, in which I’m not sure what exactly is to blame. I think the question is in aggregate does POCUS add any diagnostic/management accuracy, not is it perfect.

@aribindi @ThinkingCC @fersaurin a critical failure. Or misplaced confidence in a POCUS judgement leading someone not to course correct if possible. But outside of anchoring, I still think the POCUS should be judged against the decision that would be made in its absence, which could be the exact same one.

It is terrifying that 33% gave fluid to a struggling RV with an underfilled LV. Terrifying.

@aribindi @ThinkingCC @fersaurin Likely to benefit from a fluid load given some degree of right sided dysfunction on Echo. And then POCUS could inform a post test probability of fluids vs inotropes.

@aribindi @ThinkingCC @fersaurin For that ‘average doc in practice’ some guidance on making the decision about whether a particular patient would benefit from fluids could reasonably come from some POCUS. Reasonable minds could disagree on the exact parameters and the pre-test % of patients likely to benefit.

@Inamanotherapy @khaycock2 @NephroP @ThinkingCC Whether or not you feel there are cost, time or diagnostic yield or decision making reasons to POCUS someone or not is between you and the patient as it is any time you perform a maneuver or procedure or order a test.

@Inamanotherapy @khaycock2 @NephroP @ThinkingCC This is a false dilemma, it’s not either or, you can consider POCUS to be a component of or extension of the physical, not necessarily a replacement of it. That would be like saying getting imaging or labwork of any kind is pointless because the clinical exam is sufficient.

For the Specialist not trained in the Gen Med here is an important but overlooked tip for your patient's Creatinine problems: If the BUN/Creatinine ratio is >20- Give Fluids. The Creatinine will normalize after 24 hours If the BUN/Creatinine ratio is <20- Call the nephrologist. This is not your patinet to treat !

@jackdeliuc @PulmCrit Curious your thoughts @PulmCrit

@jackdeliuc @PulmCrit But I think some more discussion of the medicolegal landscape and the true diagnostic yield improvement of contrast outside of obvious vascular concerns on differential would be useful. Just saying the clinical risk is overblown/has changed isn’t enough at this stage IMO

modern IV contrast dye for CT scans isn’t neprotoxic. definitive imaging saves lives. this is so simple but people & journals & textbooks keep on messing it up.

@PerformativeM How do you even find this stuff if you don’t follow anyone

This shit is fucking A+ stuff. You can’t even make it up.

@PerformativeM Lol can I DM you or are you a public square only kinda guy

Yeah. Go outside or your little academic shit hole. You’ll be told to suck a dick moron. Because nurses can do your job. But go ahead. Do the winky face out in practice. Or you’ll be the cock suck that hides in academics forever.

@DrRazi4 @RobertHermanMD @PMcardioApp Does RCA being non dominant imply that LCX is supplying that inferior territory? Normally that would be RCA if RCA dominant?

@DrRazi4 @RobertHermanMD @PMcardioApp Nice thanks

77 y.o old lady treated with chest pain; treated as NSTEMI Delayed angiography after 24hours Great performance by @PMcardioApp #ECG #Cardiology #Medicalstudent

@raghu_venugopal 2) after a negative US (I assume ruling out torsion) would a CT not be the next step for an appendicitis eval? I agree broadly regarding the whole Dr. A Dr. B situation and signout culture broadly

@raghu_venugopal Some questions about this, and I wonder if this is in part due to US/Canada practice patterns 1) do you find a gynecological exam universally indicated given this patient doesn’t have any gynecological symptoms, I assume meaning no discharge?

Do women with appendicitis benefit from a gynaecological exam? The answer is obvious: they don't. And yet - that's what happens in ERs. Let me explain why. 👇👇👇 The doctors involved are all well-intentioned. Yet this is an example of "MD-first" medicine rather than "patient-first" medicine. Dr. A sees a woman with lower abdominal pain, more on the right. There are zero gyne symptoms. The pregnancy test is negative. An ultrasound is ordered to rule out an ovarian or appendix cause. Due to a delay in imaging or lack of result Dr. A hands over to Dr. B. Some argue the US may not show the cause of symptoms and Dr. B will now have to consider a gyencological exam - often to rule out an important condition - called pelvic inflammatory disease - which needs antibiotics and untreated could contribute to infertility. The problem with this is there is an important chance the US will show the cause of pain. Some feel it's now inconvenient for Dr. B to find a room, find a nurse chaperone and make the time to do the gynaecological exam. Some will argue Dr. B doesn't have the "relationship" with the patient like Dr. A. Others - like me - will argue as Dr. B - I have zero problem doing the gynaecological exam if the US is not helpful. I can find a room, I can find a nurse and I can make the time. This is a reasonably quick sensitive exam. The argument Dr. A knows the patient "better" than Dr. B isn't very strong. Let's be honest, we're all ER doctors and not their family doctor. A trusting relationship with a patient can be built quickly if the doctor tries and Dr. A may have actually only spent 5 minutes or less with the patient. The problem with "ER doctors should not handover gyne exams" in this context is that if Dr. A at the get-go just does the gyn exam before the US is resulted - some women will end up with a gynaecological exam that they never needed because they are going to the OR with proven appendicitis. The advantage of "examine everything before handing over the ultrasound" is that Dr. B. doesn't have to do the gyne exam, has to think less and can disposition the patient easier. A gynaecological exam is a very sensitive exam and I have done a few thousand. It should not be deferred when indicated - but needs a valid medical and patient-centered indication. Lessening the work of Dr. B and lessening the thinking needed of Dr. B - to me - isn't a good justification of just barrelling forward with the exam - when an important ovarian or appendix cause of pain might the the actual diagnosis that will be known shortly. I'm arguing here for a "patient first" approach rather than a "doctor first" approach. I'm arguing here that a gynaecological exam should only be offered to the patient with a solid clinical reason after other common alternative causes have been rule out. Your thoughts? Thanks for reading, Raghu @CVarnerEmerg @OntariosDoctors @NightShiftMD